Acquired Brain Injury (ABI) Service

The Acquired Brain Injury (ABI) Community Pathway provides a person-centred package of rehabilitation care, delivered in the home environment, for individuals who have experienced an acquired brain injury. Rehabilitation care is provided by a multidisciplinary Team (MDT) that may include neuropsychologists, occupational therapists and physiotherapists. The exact roles you will interact with will reflect the nature of the ongoing difficulties.

Following a referral to the ABI Community team, a typical rehabilitation journey will start with an initial period of assessment which is most usually conducted by a neuropsychologist and an occupational therapist. Assessment will include emotional wellbeing and cognitive abilities (such as memory, communication), with an emphasis on how these might impact your ability to engage in daily activities (such as personal care, access to the community, engaging in leisure activities or work).

The assessments will be reviewed by the MDT so that an individual rehabilitation package can be developed that reflects your long term rehabilitation goals. In some cases the assessment may indicate that other services are more appropriate to meet specific needs and the ABI service will make onward referrals and signpost at this stage.

Each ABI is unique and therefore each rehabilitation journey is unique, however as a guide you might expect to be supported through the community pathway for a 12 to 16 week episode. This is a guideline only and care is taken to ensure that a patient is only discharged from the service when there is agreement that their rehabilitation goals are met. Within the community pathway there is provision to support engagement with other groups (such as Headway, Stroke Association) that may be beneficial to support your ongoing recovery journey.

The scope of the service in the community includes:

• Support the transition from post-acute rehabilitation through provision of episodes of person centred, evidence based rehabilitation solutions.
• Intervention at any point of the recovery pathway to support further transition such as community integration or return to work.
• Consultation to community rehabilitation services to provide clinical oversight and guidance to community teams that are providing rehabilitation to people with complex presentation resulting from ABI.
• Liaison with a wide range of services including mental health services, local authority, voluntary services and employers to manage transitions and facilitate sustainable sources of support.
• Planned review in order to prevent breakdown of packages.
• Clinical input and training to support packages of care commissioned through continuing healthcare or the local authority which can result in a reduction of care costs.

For patients whose needs are beyond the scope of local services, the ABI service provides clinical case management. This role is underpinned by specialist clinical skills and in-reaches to the acute hospitals once the patient is medically stable. Through assessment and identification of the patient’s clinical needs local solutions are considered where appropriate.

Where specialist in-patient rehabilitation is required the role of the ABI clinical coordinator is to guide placement to either:

• Level 1 specialist rehabilitation under the NHS England contract
• Make onward referrals to a range of specialist providers in the independent sector.

Once a placement option has been identified the clinical coordinator facilitates funding and regularly monitors the placement on a 6 or 12 weekly basis in order to ensure quality and review the appropriateness of the placement.

Discharge planning is facilitated by the clinical coordinator and the wider multidisciplinary team (MDT).

Patients are transferred home, linking in with the ABI community rehabilitation pathway and other community services.

When the risks associated with living at home cannot be effectively mitigated, a longer term placement is facilitated with assessment and coordination of the appropriate funding stream. This could be continuing healthcare or social services funding.

Some patients who experience stroke may be unable to return home straight away due to the nature of their rehabilitation needs. This can be due to complexity or intensity.

The therapists in the acute hospital will consider if the patient’s rehabilitation can be supported at home through the early supported discharge team.

If the patients rehabilitation can not be supported at home through the early supported discharge team, a referral will be made to the ABI team. Our team will arrange for an interim placement in one of four local specialist rehabilitation units depending on the patient’s specific needs.

A placement is funded by the NHS for an average of 6 weeks with some patients returning to the community earlier and some requiring a longer stay.

The ABI Service will monitor progress with a review at 4 weeks and facilitate discharge when patient’s needs can be met in the community or refer to local services as appropriate.

If a longer term placement is required a referral will be made to social services.